Nursing Elites

1. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the nurse to take?

• A. Monitor the client's blood glucose level.
• B. Encourage the client to increase fluid intake.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: A

Rationale: The most critical action for the nurse to take when a client with diabetes mellitus presents with symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps in assessing the client's current glycemic status and guides further interventions. Encouraging increased fluid intake (Choice B) may be beneficial in managing dehydration caused by polyuria, but it does not address the underlying cause of hyperglycemia. Administering insulin as prescribed (Choice C) may be necessary based on the blood glucose monitoring results, but monitoring should precede any medication administration. Assessing the client's urine output (Choice D) is important but does not directly address the primary concern of evaluating and managing hyperglycemia in a client with diabetes.

2. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?

• A. Offer small sips of water through a straw
• B. Place tongue blade on back half of tongue
• C. Use a penlight to observe back of the oral cavity
• D. Auscultate breath sounds after the client swallows

Correct answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

3. A nurse is planning care for a client who has a prescription for knee-length anti-embolic stockings. Which of the following actions should the nurse take?

• A. Remove the client’s stockings at least once during each shift
• B. Roll the top of the client’s stockings down to just below the knee
• C. Seat the client in a chair for 30 minutes prior to applying stockings
• D. Measure the length of the client’s leg from the heel to the gluteal fold

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the client’s stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client’s leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.

4. A client is scheduled for hip surgery in an hour. Which of the following actions is the nurse’s priority?

• A. Ensure that the client signs the consent form.
• B. Lock the client’s valuables in a secure location.
• C. Verify the client’s lab values in the medical record.
• D. Administer the prescribed preoperative sedative.

Correct answer: A

Rationale: The nurse’s priority is to ensure that the client signs the consent form before the hip surgery. This is crucial as it ensures that the client has provided informed consent for the procedure. Locking valuables, verifying lab values, and administering sedatives are important tasks but ensuring consent takes precedence as it directly impacts the client’s right to make decisions about their care.

5. A healthcare professional is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the healthcare professional question?

• A. Oral psyllium (Metamucil)
• B. Oral potassium supplement
• C. Parenteral half normal saline
• D. Parenteral albumin (Albuminar)

Correct answer: D

Rationale: The correct answer is D, Parenteral albumin (Albuminar). Parenteral albumin is not typically indicated for dehydration resulting from diarrhea. In this case, fluid replacement therapy with intravenous fluids such as parenteral half normal saline would be more appropriate. Oral psyllium and oral potassium supplement are not the primary interventions for managing dehydration due to watery diarrhea. Oral psyllium is a fiber supplement used for constipation rather than diarrhea. Oral potassium supplements may be necessary if potassium levels are low due to dehydration, but the priority is fluid replacement. Therefore, choices A and B are less relevant in this scenario.

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